<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Department_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-department_id" data-rule="required" data-source="dicts\Department\getDepartmentList222"
                data-field="department" class="form-control selectpage" name="row[department_id]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Operator')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-operator" readonly="readonly" data-rule="required" class="form-control" name="row[operator]"
                type="text" value={$operator|htmlentities}>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Beds')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-beds" min="0" class="form-control" name="row[beds]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Total_nurses_start')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-total_nurses_start" min="0" class="form-control" name="row[total_nurses_start]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Total_nurses_end')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-total_nurses_end" min="0" class="form-control" name="row[total_nurses_end]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Ward_nurses_start')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-ward_nurses_start" min="0" class="form-control" name="row[ward_nurses_start]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Ward_nurses_end')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-ward_nurses_end" min="0" class="form-control" name="row[ward_nurses_end]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Nurse_hours')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-nurse_hours" min="0" class="form-control" name="row[nurse_hours]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Catheter_count')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-catheter_count" min="0" class="form-control" name="row[catheter_count]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gastric_count')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-gastric_count" min="0" class="form-control" name="row[gastric_count]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Central_catheter_coun')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-central_catheter_coun" min="0" class="form-control" name="row[central_catheter_coun]"
                type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Tracheal_count')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-tracheal_count" min="0" class="form-control" name="row[tracheal_count]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Vap_count')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-vap_count" min="0" class="form-control" name="row[vap_count]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Clabsi_count')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-clabsi_count" min="0" class="form-control" name="row[clabsi_count]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Cauti_count')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-cauti_count" min="0" class="form-control" name="row[cauti_count]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Vent_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-vent_days" min="0" class="form-control" name="row[vent_days]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Restraint_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-restraint_days" min="0" class="form-control" name="row[restraint_days]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Stage2_ulcer')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-stage2_ulcer" min="0" class="form-control" name="row[stage2_ulcer]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Stage1_ulcer')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-stage1_ulcer" min="0" class="form-control" name="row[stage1_ulcer]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Falls_count')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-falls_count" min="0" class="form-control" name="row[falls_count]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Falls_severity1')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-falls_severity1" min="0" class="form-control" name="row[falls_severity1]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Falls_severity2')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-falls_severity2" min="0" class="form-control" name="row[falls_severity2]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Falls_severity3')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-falls_severity3" min="0" class="form-control" name="row[falls_severity3]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Falls_death')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-falls_death" min="0" class="form-control" name="row[falls_death]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Falls_injury')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-falls_injury" min="0" class="form-control" name="row[falls_injury]" type="number">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>